HospitalInspections.org

Based on record review, document review, and interview the facility failed to:

A.) Protect the patient's right to make informed decisions regarding their treatment in 5 (Patients #2, #4, #6, #17, and #21) of 25 medical records reviewed. The facility failed to ensure that patients or their representatives were provided with the risks and benefits prior to being transferred to another facility.

B.) Follow their own policy and procedures regarding Informed consent.

C.) Ensure that informed consent had been completed and documented in 5 (Patients #2, #4, #6, #17, and #21) of 25 medical records reviewed


This deficient practice had the likelihood to cause harm to all patients being transferred to another facility.


Findings include:

Patient #2
A review of Patient #2's medical record revealed:

Patient #2 was admitted to the facility on 4/18/2019. Patient #2 was transferred to another facility on 4/24/2019 for a higher level of care. Patient #2 was transferred by EMS Ambulance. The Memorandum of Transfer was dated and signed on 4/24/2019. No signed informed consent by Patient #2 or their representative to transfer Patient #2 to another facility was found within Patient #2's medical record. Staff #5 and Staff #9 confirmed the findings.


Patient #4
A review of Patient #4's medical record revealed:

Patient #4 was admitted to the facility on 4/24/2019. Patient #4 was transferred to another facility on 4/25/2019. Patient was transported by EMS Ambulance. The Memorandum of Transfer was dated and signed on 4/25/2019. No signed informed consent by Patient #4 or their representative to transfer Patient #4 to another facility was found within Patient #4's medical record. Staff #5 and Staff #9 confirmed the findings.


Patient #6
A review of Patient #6's medical record revealed:

Patient #6 was admitted to the facility on 4/16/2019. Patient #6 was transferred to another facility on 4/23/2019. Patient was transported by EMS Ambulance. The Memorandum of Transfer was signed on 4/23/2019. No signed informed consent by Patient #6 or their representative to transfer Patient #6 to another facility was found within Patient #6's medical record. Staff #5 and Staff #9 confirmed the findings.


Patient #17
A review of Patient #17's medical record revealed:

Patient #17 was admitted to the facility on 4/22/2019. Patient #17 was transferred to another facility on 4/22/2019 for a higher level of care. Patient was transported by EMS Ambulance. The Memorandum of Transfer was signed on 4/22/2019. No signed informed consent by Patient #17 or their representative to transfer Patient #17 to another facility was found within Patient #17's medical record. Staff #5 and Staff #9 confirmed the findings.


Patient #21
A review of Patient #21's medical record revealed:

Patient #21 was admitted to the facility on 4/17/2019. Patient #21 was transferred to another facility on 4/22/2019 for a higher level of care. Patient was transported by EMS Ambulance. The Memorandum of Transfer was signed on 4/22/2019. No signed informed consent by Patient #21 or their representative to transfer Patient #21 to another facility was found within Patient #21's medical record. Staff #5 and Staff #9 confirmed the findings.



Review of policy titled, "Consents, Informed," PC 684, with a revision date of March 2017 was as follows:

POLICY
" ...The policy regarding Informed Consent for medical treatment or surgical procedure is based on the Rules and Regulations of the Medical Staff of CHI St. Joseph Health System. Consent will be obtained from all patients or their legal guardian prior to performing any procedure or treatment except for emergency situations ..."




An interview was conducted with Staff #5 on 6/27/2019 after 9:00 AM. Staff #5 was asked if the hospital policy required a signed consent form for all transferred patients. Staff #5 stated, "Yes they are required unless the patient has been discharged from the hospital and going to a Rehabilitation Center for further care."


On 6/27/2019 after 12:00 PM, Staff #5 and Staff #9 confirmed the above findings.